[Excerpts from the Plenary Session held at the Appalachian Regional Commission’s Annual Meeting in Prestonsburg, KY, September 8, 2011.]
Genetic Endowment: There are no data suggesting Appalachians are more likely to be genetically susceptible to disease than other populations. In particular, the available literature does not substantiate long-held beliefs of an increased rate of abnormal genetic conditions in the region due to inbreeding.
Physical Environment: People in Appalachia experience higher riskscape exposures across the spectrum of behavioral, socioeconomic, and environmental threats. Coal mining and coal combustion are two serious environmental threats. Water quality is an issue in some parts of Appalachia, potentially contributing to the choice of soft drinks or juice drinks for young children and to subsequent health effects. However, rurality is an important aspect of the physical environment that must be considered when examining the region’s health disparities.
Social Environment: Appalachian culture is frequently used as a nebulous explanatory variable of the region’s health status. But the available science does not support this position. It is difficult to conceive of an accurate definition of an “Appalachian culture” for some 25 million people living in 13 states from a multitude of backgrounds and life experiences. This is not to say that local cultures do not exit, or that cultures of the local communities should not be taken into consideration. More importantly, one must take into consideration socioeconomic status in terms of education, income, and occupation.
Individual Response: Extensive epidemiological research has determined that specific health behaviors, such as smoking, sedentary lifestyle, and diet, are major contributors to Appalachia’s health disparities. However, these behaviors are not unique to Appalachians. Suggesting that these disparities are due to a lifestyle that is uniquely “Appalachian” is not supported by existing research.
Health Care System: The region as a whole does not contain a shortage of medical professionals when compared to the rest of the country, but suffers from an uneven distribution of health care resources with those resources concentrated in the more prosperous and populated Appalachian counties. The underlying cause of the region’s poor health outcomes is the general absence of community-linked and community-responsive systems of health care across the region.
Health Disparities: Appalachians constitute a health disparity population. They experience higher rates of chronic illness and mortality from the major causes of death when compared to the rest of the country. Most troubling is the high premature mortality in the 35-64 age group. In addition, health disparities exist within Appalachia across the subregions and between the urban and rural areas.
Cardiovascular Disease: Nearly 15 percent of hospitalizations in Appalachia are due to heart disease, exceeding the percent of hospitalizations due to chronic obstructive pulmonary disorders, all cancers, stroke, and diabetes combined. Central Appalachia has particularly high rates of hospitalization for heart disease. The Appalachian mortality rate from heart disease was four times the national Healthy People 2010 goal.
Diabetes: Diabetes is more prevalent in the Appalachian region than in other areas of the United States. Those living in the distressed counties of Appalachia are at the greatest risk for diabetes.
Cancer: Cancer incidence and mortality rates are greater for the Appalachian region than for the rest of the country, particularly cancers of the cervix, colon/rectum, and lung/bronchus. At least three types of cancer-related behaviors may be major contributors: tobacco use; energy balance and obesity; and sexual behaviors, especially those related to human papillomavirus. The prevalence of cancer screening is significantly lower among Appalachian than among non-Appalachian adults.
Chronic Kidney Disease: Appalachians may be at increased risk for chronic kidney disease although this has not been quantified directly. Appalachians are at risk for developing two major causes of chronic kidney disease, diabetes and hypertension, due to growing incidences of obesity, sedentary lifestyles, and poor nutrition. The major concern is that persons with kidney disease are often unaware that they have the disease, resulting in many undiagnosed cases.
Obesity: The Appalachian region is one of the nation’s most obese regions as well as having higher rates of food insecurity than the rest of the country. However, here lies a conflict: there are more supermarkets and grocery stores per capita in the distressed and at-risk counties where obesity rates are higher than in other counties.
Trauma: Appalachia faces unusual challenges related to occupations and recreational activities that expose residents to high risk of injury, particularly coal mining, logging, and all-terrain vehicle use. However, trauma care in Appalachia is unevenly distributed and generally underdeveloped, unorganized, fragmented, understaffed, and underfunded
Mental Health: Appalachians have higher rates of psychological distress, depression, and suicide relative to the rest of the nation, due in part to the prevalence of social, economic, and ecological stressors. Appalachians with mental health problems may not be receiving adequate outpatient treatment or timely access to inpatient services, resulting in increased use of emergency services. Rural Appalachians benefit little from available mental health services. This is not only due to the potential lack of ability to afford mental health care, but also because the organization and delivery of available mental health services may discourage service utilization.
Substance Abuse: Nonmedical use of prescription drugs, production and use of methamphetamine, and cultivation and use of marijuana are major issues facing the region particularly in the rural areas. Influenced by a number of factors including poor economic prospects, high unemployment rates, limited transportation networks, long distances to medical facilities, and a scarcity of treatment facilities and service organizations, the abuse of any legal or illegal drug can have devastating consequences for individuals, families, and communities.
Oral Health: Appalachians historically have been affected more by caries and other oral diseases than other groups in the nation, with toothlessness among adults being a major problem. Despite a high rate of sealant use, the rate of untreated caries among Appalachian children remains much higher than national norms. On the positive side, evidence suggests that the oral health of children is better than that of their parents due to parents placing a higher priority on their children’s dental care.
The book goes beyond documenting Appalachian health inequalities; it examines some of the more effective programs for dealing with them. Case studies highlight the key role of local communities in defining needs and promoting health care services. The volume also contains recommendations for improvement in health policies, and indicates where data are lacking for program design and how they might be obtained.